Dr. Smith's ECG Blog

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. But STEMI criteria is only 43% sensitive for OMI.[1] De Alencar Neto.

STEMI 118

STEMI Coronary ALS Emergency Department 118

REBEL EM

SEPTEMBER 14, 2023

We don’t know any of this information unfortunately and all are key in patient selection The median lactate level before revascularization was 6.9mmol/L (Range 4.6 Control: 53.4% D ECLS: 18.2% Control 8.7% Control 38.0% Control: 49.0% RR 0.98; 95% CI 0.80 to 1.19; p = 0.81 vs 13.9% (RR 0.58; 95% CI 0.33 vs 22.6% (RR 1.03; 95% CI 0.88

Life Support 137

Life Support Coronary CPR ICU 137

Dr. Smith's ECG Blog

OCTOBER 27, 2024

This was sent to me with no clinical information, and my initial impression viewing it on my phone was "It’s a tricky one. Initial 4th generation troponin I was 10 ng/mL is consistent with large MI due to acute coronary occlusion (OMI). There are moderate coronary artery calcifications. Here is his EMS ECG: What do you think?

STEMI 116

STEMI ED Coronary EMS 116

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. This was shown to me with no clinical information and I said "It is VT until proven otherwise." Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease. Initial ED ECG: What do you think?

Coronary 136

Coronary OR EMS ED 136

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

But do they represent acute coronary occlusion? But coronaries were normal, and serial high sensitivity troponin was undetectable. Based on ECG changes and echo findings, the patient was diagnosed as coronary vasospasm. I sent both ECGs to Dr. Smith, with the only information that these were prior vs new ECG.

STEMI 88

STEMI Coronary OR ED 88

ALiEM

OCTOBER 20, 2023

A 50-year-old Caucasian female with a history of hypertension, coronary artery disease, and insulin-dependent diabetes mellitus presents to the emergency department with a complaint of painful sores on the top of her left foot. View other cases from this Clinical Image Series on ALiEM.

Plasma 161

Plasma Coronary Emergency Department OR 161

Dr. Smith's ECG Blog

JANUARY 9, 2023

This was sent to me with no information and I immediately replied that it was diagnostic of LAD OMI. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus.

Coronary 52

Coronary STEMI Heart Attack OR 52

REBEL EM

MARCH 30, 2023

Clinical Question : In patients who suffer an OHCA without ST-segment elevation on the post-resuscitation ECG, will early coronary angiogram (CAG) vs. delayed CAG improve outcomes? Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial. Janssens, G.

Coronary 83

Coronary CPR OR ICU 83

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. I sent it to 5 of my OMI friends without any clinical information or outcome and all 5 independently responded with exactly the same diagnosis: "reperfused inferior OMI".

Defibrillator 130

Defibrillator Coronary STEMI CPR 130

ECG & Echo Learning

OCTOBER 28, 2023

Table 1 provides a summary of the indications, contraindications, dosage, administration, warnings, precautions, and other relevant information for the drug Prasugrel. – For UA/NSTEMI patients undergoing coronary angiography within 48 hours, the dose should be given at the time of PCI. – Active bleeding.

Coronary 52

Coronary OR 52

Dr. Smith's ECG Blog

OCTOBER 15, 2024

Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion. The patient is a 75-year old man with known coronary disease, including prior LAD and LCx OMI. That this patient has severe underlying coronary disease is indisputable.

OR 106

OR STEMI Coronary ED 106

Dr. Smith's ECG Blog

OCTOBER 3, 2024

This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. Coronaries were clean. If a final test was perceived as "needed" — perhaps a normal coronary CT angiogram could have helped to avoid cardiac catheterization. I assumed it was a patient with acute chest pain. What do you think, Steve? Real or just fake?"

E-9-1-1 110

E-9-1-1 Coronary ALS ED 110

Dr. Smith's ECG Blog

JULY 2, 2023

Outcome The only followup we got was that the patient is undergoing Coronary Bypass (CABG) of LAD, 2nd Obtuse Marginal, and Left Posterolateral coronaries. We don't know if he had a stress test, a CT Coronary angiogram, or they just decided to do an angiogram. Thus, Unstable Angina. I’m not sure if you know who the queen is.

ACS 52

ACS Coronary OR 52

The Skeptics' Guide to EM

OCTOBER 22, 2017

Studies have shown that oxygen can cause vasoconstriction, increase blood pressure and decrease coronary artery blood flow ( Kones et al AM J Med 2011). They felt this would help inform guideline writers on making recommendations in this area. Class IIb, LOE C-LD)

Emergency Medical Services 130

Emergency Medical Services Coronary ALS STEMI 130

EMDocs

SEPTEMBER 15, 2023

ST segment elevation, or even an isoelectric ST segment, in these leads is abnormal and should make us concerned for ischemia Source Acute Coronary Occlusion in a Patient With Prior Known Right Bundle Branch Block: Another Chink in the Armor for the ST-Elevation Myocardial Infarction Criteria. Ann Emerg Med. 2023 Aug;82(2):219-221.

Emergency Medical Services 61

Emergency Medical Services Coronary Emergency Department EMS 61

Dr. Smith's ECG Blog

JANUARY 8, 2024

I was reviewing ECGs for a study, and came across this one, and was able to get all the clinical information: What do you think? She went to angio and had normal coronaries. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. I discussed all results with patient.

Coronary 71

Coronary STEMI EMS OR 71

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Posterior leads are unnecessary if anterior leads are diagnostic According to the STEMI paradigm an ECG has to have ST elevation to diagnose acute coronary occlusion, and if there’s no ST elevation on anterior leads you can look for it on posterior leads. If so, how will they change management?

STEMI 111

STEMI ACS Coronary OR 111

Dr. Smith's ECG Blog

JUNE 15, 2023

Written by Pendell Meyers Both of these cases were sent to me with no information other than adults with acute chest pain. What would be your response? Case 1: Case 2: What if I told you that Case 1 has an abnormal initial troponin, and Case 2 has a normal initial troponin? Case 1 An elderly male presented with chest pain.

STEMI 93

STEMI Coronary ACS OR 93

Dr. Smith's ECG Blog

OCTOBER 12, 2023

Accompanying the ECGs is some clinical information. Look at the ECGs and consider the timeline and other information. Would you change you interpretation if the following information was added? B elow are 4 ECGs from the same patient. At the bottom will be five alternative clinical scenarios to explain the findings.

Coronary 103

Coronary OR ED 103

EM Literature of Note

OCTOBER 18, 2021

Pervasive use of CT coronary angiography has been an unnecessary feature of the evaluation of patient with low-risk chest pain for the better part of a decade now. Patients were eligible by symptoms of an acute coronary syndrome, supported by ECG changes, an elevated troponin, or a history of ischemic heart disease.

Coronary 40

Coronary CAD ED OR 40

EMDocs

SEPTEMBER 26, 2024

Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. If you have a story to share click here. Who is responsible for notifying patients of post discharge findings?

Emergency Department 74

Emergency Department ED ALS Coronary 74

Dr. Smith's ECG Blog

DECEMBER 9, 2023

I read this blinded, with no clinical information, and read it as inferior OMI. The Queen of Hearts interprets it blinded also (no clinical information and no previous ECGs or serial ECGs). A Coronary angiogram from 8 years prior revealed that he had had an inferior posterior STEMI at the time due to 100% occlusion of the proximal RCA.

STEMI 107

STEMI Coronary ED Paramedic 107

Dr. Smith's ECG Blog

MAY 16, 2023

Dr. Singer sent this to me with just the information: "~40 year old with acute chest pain". Other outcome information is not available. Sadly, I did not receive enough information to adjudicate whether this patient has pericarditis or not. Emergent CT coronary angio also likely has a role in such cases.

Coronary 52

Coronary STEMI ED OR 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. Incidence of an acute coronary occlusion. Incidence of an Acute Coronary Occlusion. link] Harhash AA et al.

ACS 52

ACS Coronary STEMI ALS 52

Dr. Smith's ECG Blog

MARCH 17, 2023

She had a prior history of "NSTEMI" one month ago, during which she had a coronary angiogram reportedly showing no stenosis in any coronary artery. I sent the first ECG with no information at all, and without the old ECG, to Steve Smith who immediately just texted back: "pulse tapping." Her vitals were within normal limits.

Coronary 52

Coronary Emergency Department ED OR 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). It can only be seen by IVUS.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion.

STEMI 101

STEMI Coronary ACS ED 101

Dr. Smith's ECG Blog

AUGUST 9, 2024

Learning points: Both patients and other medical providers can report confusing and often contradictory information that obfuscates the diagnosis (in this case, WPW). Serial ECGs enhance the diagnosis of acute coronary syndrome. If the story and ECG findings are concerning, use your clinical judgment to advocate for PCI. Washam, J.

STEMI 84

STEMI Coronary Heart Attack ACS 84

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

Here is his triage ECG: PM Cardio version: With no other information at all, I sent this ECG to Dr. Smith, who replied: "I think it is real. At times — the initial subtle findings simply represent a phase of "pseudo-normalization" that may occur soon after spontaneous reopening of an acutely occluded coronary artery. STD in V4-5 too."

Coronary 52

Coronary Heart Attack ED CPR 52

Dr. Smith's ECG Blog

JUNE 17, 2024

If this EKG were handed to you to screen from triage without any clinical information, what would you think? Electrocardiographic Differentiation Between Acute Pulmonary Embolism and Acute Coronary Syndromes on the Basis of Negative T Waves - ScienceDirect. What do you think? In fact, Kosuge et al. Accessed May 28, 2024.

E-9-1-1 136

E-9-1-1 ACS Emergency Department Coronary 136

Dr. Smith's ECG Blog

AUGUST 6, 2024

All coronary arteries were patent without atherosclerotic change. Dr. Myocarditis can be very difficult to separate from OMI on ECG, and often some form of coronary artery imaging will need to be done to rule out OMI. The ECG shows slight ST Elevation in an inferolateral distribution. Notice how QOH is not fooled by this ST-Elevation.

Coronary 85

Coronary OR STEMI EMS 85

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

Defibrillator 113

Defibrillator Coronary ALS STEMI 113

Dr. Smith's ECG Blog

AUGUST 20, 2024

Record serial ECGs == MY Comment , by K EN G RAUER, MD ( 8/16 /2024 ): == It is always a challenge to interpret an ECGs from a patient with known coronary disease, but no prior tracing for comparison. Given the known history of coronary disease — multiple previous ECGs certainly were done. Use the Queen of Hearts 2.

Coronary 64

Coronary OR 64

Dr. Smith's ECG Blog

MAY 23, 2023

The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. EMS arrived and recorded this ECG: What do you think?

STEMI 90

STEMI Coronary Paramedic OR 90

Dr. Smith's ECG Blog

APRIL 21, 2023

I sent the ECG to Dr. Meyers without any other information. But STEMI criteria has poor sensitivity for acute coronary occlusion. Like the initial hemoglobin level in acute hemorrhage, the initial troponin in acute coronary occlusion can be falsely reassuring. This is diagnostic of inferoposterior OMI.

STEMI 52

STEMI Coronary EMR EMT 52

Dr. Smith's ECG Blog

JULY 16, 2022

If you put the inferior and posterior findings together, it is diagnostic of OMI This was read as "inferior ischemia" without any other information by Dr. Richard Gray and as probable reperfused inferior-posterior OMI much later by both me and Pendell Meyers, also without any clinical information.

Coronary 52

Coronary ED EMS Critical Care 52

Dr. Smith's ECG Blog

MARCH 13, 2024

Distilling this case into its most salient components, a man with multiple risk factors for coronary disease is presenting with several days of chest pain and markedly elevated troponin with no other reason to explain the lab abnormality ( e.g. sepsis). High sensitivity troponin I (hsTnI) obtained around that time was 5548 ng/L (ref. <

Coronary 85

Coronary ACS Emergency Management Emergency Manager 85